Client Informed Consent and Release Form
I, the undersigned, acknowledge and agree to the following before receiving any spa, esthetic, or skincare treatments, including chemical peels, facials, and waxing, at Anna Lucille Beauty:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Do you have any allergies?
*
Yes
No
If yes, please list your allergies:
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you have any medical conditions? (Select all that apply)
*
Diabetes
Autoimmune disorder
Heart condition
Epilepsy
Skin conditions (e.g., eczema, psoriasis)
Bleeding disorders
None
Other (please specify)
Are you using any of the following at home?
*
Retinol, Tretinoin, Retin-A
Benzoyl peroxide,
AHA/BHA acids
Vitamin C
None
Are you currently pregnant or breastfeeding?
*
Yes
No
Are you currently taking any medications? (especially Retin-A, Accutane, antibiotics, or steroids?)
*
Yes
No
Other (please specify)
Any recent cosmetic procedures or skincare treatments? Have you had Botox or dermal fillers, lasers, or peels within the past 2 weeks?
*
Yes
No
Other (please specify)
Recent Waxing History - Have you waxed the area to be treated recently?
*
Yes
No
Other (please specify)
How would you describe your skin?
*
Normal
Dry
Oily
Combination
Sensitive
Acne-prone
Please read each statement and check the box
*
I understand that skincare treatments may cause temporary redness, sensitivity, breakouts, peeling, dryness, or irritation.
I understand results vary based on my skin and homecare routine.
I understand that failing to disclose medical conditions, procedures, or products may result in adverse reactions.
I understand that the esthetician cannot guarantee specific results.
I agree to follow all aftercare instructions provided to me.
I release Anna Lucille Beauty and its esthetician from liability for reactions that occur due to my undisclosed conditions or the normal risks of treatment.
Do you consent to receive occasional promotional marketing text messages from Anna Lucille Beauty?
*
Yes
No
Where did you hear about Anna Lucille Beauty?
Client Signature
*
Submit Consent Form
Submit Consent Form
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